APPENDIX B



APPENDIX DREQUIRED FORMSFORINVITATION FOR BIDS (IFB)Rev. 6/07/18EXHIBITSBUSINESS FORMS1BIDDER’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT AND CBE INFORMATION2PROSPECTIVE CONTRACTOR REFERENCES 3PROSPECTIVE CONTRACTOR LIST OF CONTRACTS 4PROSPECTIVE CONTRACTOR LIST OF TERMINATED CONTRACTS5CERTIFICATION OF NO CONFLICT OF INTEREST6FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATION7REQUEST FOR PREFERENCE PROGRAM CONSIDERATION 8BIDDER’S EEO CERTIFICATION9ATTESTATION OF WILLINGNESS TO CONSIDER GAIN/GROW PARTICIPANTS10 CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM CERTIFICATION FORM AND APPLICATION FOR EXCEPTION11CHARITABLE CONTRIBUTIONS CERTIFICATIONPRICING FORMS12PRICING SHEET (INTENTIONALLY NOT ATTACHED)13CERTIFICATION OF INDEPENDENT PRICE DETERMINATION AND ACKNOWLEDGEMENT OF IFB RESTRICTIONSADDITIONAL BUSINESS FORM 14CERTIFICATION OF COMPLIANCE WITH THE COUNTY’S DEFAULTED PROPERTY TAX REDUCTION PROGRAMHUMAN TRAFFICKING15ZERO TOLERANCE POLICY ON HUMAN TRAFFICKING CERTIFICATIONINTEGRATED PEST MANAGEMENT PROGRAM16INTENTIONALLY OMITTED17 COMPLIANCE WITH FAIR CHANCE EMPLOYMENT HIRING PRACTICES CERTIFICATIONREQUIRED FORMS - EXHIBIT 1BIDDER’S ORGANIZATION QUESTIONNAIRE/AFFIDAVIT AND CBE INFORMATIONPlease complete, sign and date this form. The person signing the form must be authorized to sign on behalf of the Bidder and to bind the applicant in a Contract.Is your firm a corporation or limited liability company (LLC)? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Legal Name (found in Articles of Incorporation) __________________________________________State __________________________________________________ Year Inc. ________________If your firm is a limited partnership or a sole proprietorship, state the name of the proprietor or managing partner: ___________________________________________________________3.Is your firm doing business under one or more DBA’s? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Name County of Registration Year became DBA___________________________________ ________________________ ______________________________________________________ ________________________ ___________________4.Is your firm wholly/majority owned by, or a subsidiary of another firm? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Name of parent firm: _______________________________________________________________State of incorporation or registration of parent firm: _______________________________________5.Has your firm done business as other names within last five (5) years? FORMCHECKBOX Yes FORMCHECKBOX No If yes, complete:Name _________________________________________________ Year of Name Change ______Name _________________________________________________ Year of Name Change ______6.Is your firm involved in any pending acquisition or mergers, including the associated company name? FORMCHECKBOX Yes FORMCHECKBOX No If yes, provide information:________________________________________________________________________________________________________________________________________________________________I.FIRM/ORGANIZATION INFORMATION: The information requested below is for statistical purposes only. On final analysis and consideration of award, contractor/vendor will be selected without regard to race/ethnicity, color, religion, sex, national origin, age, sexual orientation or disability.Business Structure: Sole Proprietorship Partnership Corporation Non-Profit Franchise Other (Specify) ___________________________________________________________________Total Number of Employees (including owners):Race/Ethnic Composition of Firm. Distribute the above total number of individuals into the following categories:Race/Ethnic CompositionOwners/Partners/Associate PartnersManagersStaffMaleFemaleMaleFemaleMaleFemaleBlack/African American??????Hispanic/Latino??????Asian or Pacific Islander??????American Indian??????Filipino??????White??????II.PERCENTAGE OF OWNERSHIP IN FIRM: Please indicate by percentage (%) how ownership of the firm is distributed.Black/African AmericanHispanic/ LatinoAsian or Pacific IslanderAmerican IndianFilipinoWhiteMen%%%%%%Women%%%%%%CERTIFICATION AS MINORITY, WOMEN, DISADVANTAGED AND DISABLED VETERAN BUSINESS ENTERPRISES: If your firm is currently certified as a minority, women, disadvantaged or disabled veteran owned business enterprise by a public agency, complete the following and attach a copy of your proof of certification. (Use back of form, if necessary.)Agency NameMinorityWomenDisadvantagedDisabled VeteranOtherBidder further acknowledges that if any false, misleading, incomplete, or deceptively unresponsive statements in connection with this bid are made, the bid may be rejected. The evaluation and determination in this area shall be at the Director’s sole judgment and his/her judgment shall be final.DECLARATION: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.BIDDER NAME:COUNTY WEBVEN NUMBER:ADDRESS:PHONE NUMBER:E-MAIL:INTERNAL REVENUE SERVICE EMPLOYER IDENTIFICATION NUMBER:CALIFORNIA BUSINESS LICENSE NUMBER:BIDDER OFFICIAL NAME AND TITLE (PRINT):SIGNATUREDATEREQUIRED FORMS - EXHIBIT 2PROSPECTIVE CONTRACTOR REFERENCESContractor’s Name: _______________________________List Three (3) References where the same or similar scope of services were provided in order to meet the Minimum Requirements stated in thissolicitation.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.REQUIRED FORMS - EXHIBIT 3PROSPECTIVE CONTRACTOR LIST OF CONTRACTSContractor’s Name: _______________________________List of all public entities for which the Contractor has provided service within the last three (3) years. Use additional sheets if necessary.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.4. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.5. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. # of Years / Term of Contract Type of Service Dollar Amt.REQUIRED FORMS - EXHIBIT 4PROSPECTIVE CONTRACTOR LIST OF TERMINATED CONTRACTSContractor’s Name: ______________________________List of all contracts that have been terminated within the past three (3) years.1. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:2. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:3. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:4. Name of Firm Address of Firm Contact Person Telephone # Fax # ( ) ( )Name or Contract No. Reason for Termination:REQUIRED FORMS - EXHIBIT 5CERTIFICATION OF NO CONFLICT OF INTERESTThe Los Angeles County Code, Section 2.180.010, provides as follows:CONTRACTS PROHIBITEDNotwithstanding any other section of this Code, the County shall not contract with, and shall reject any bids submitted by, the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract:Employees of the County or of public agencies for which the Board of Supervisors is the governing body;Profit-making firms or businesses in which employees described in number 1 serve as officers, principals, partners, or major shareholders;Persons who, within the immediately preceding 12 months, came within the provisions of number 1, and who:Were employed in positions of substantial responsibility in the area of service to be performed by the contract; orParticipated in any way in developing the contract or its service specifications; and4.Profit-making firms or businesses in which the former employees, described in number 3, serve as officers, principals, partners, or major shareholders. Contracts submitted to the Board of Supervisors for approval or ratification shall be accompanied by an assurance by the submitting department, district or agency that the provisions of this section have not been violated.____________________________________________________Bidder Name____________________________________________________Bidder Official Title____________________________________________________Official’s SignatureREQUIRED FORMS - EXHIBIT 6FAMILIARITY WITH THE COUNTY LOBBYIST ORDINANCE CERTIFICATIONThe Bidder certifies that:it is familiar with the terms of the County of Los Angeles Lobbyist Ordinance, Los Angeles Code Chapter 2.160;that all persons acting on behalf of the Bidder’s organization have and will comply with it during the bid process; andit is not on the County’s Executive Office’s List of Terminated Registered Lobbyists. Signature:_________________________________ Date:__________________________REQUIRED FORMS - EXHIBIT 7REQUEST FOR PREFERENCE CONSIDERATIONINSTRUCTIONS: Businesses requesting preference consideration must complete and return this form for proper consideration of the bid. Businesses may request consideration for one or more preference programs. Check all certifications that apply.*I meet all of the requirements and request this bid be considered for the Preference Program(S) selected below. a copy of the CERTIFICATION letter issued by the Department of Consumer and Business Affairs (DCBA) is attached.-6794512382500? Request for Local Small Business Enterprise (LSBE) Program Preference?Certified by the State of California as a small business and has had its principal place of business located in Los Angeles County for at least one (1) year; or?Certified as a LSBE with other certifying agencies under DCBA’s inclusion policy that has its principal place of business located in Los Angeles County and has revenues and employee size that meet the State’s Department of General Services requirements; and-10795026987500?Certified as a LSBE by the DCBA.? Request for Social Enterprise (SE) Program Preference?A business that has been in operation for at least one year providing transitional or permanent employment to a Transitional Workforce or providing social, environmental and/or human justice services; and-10795022034500?Certified as a SE business by the DCBA. ? Request for Disabled Veterans Business Enterprise (DVBE) Program Preference?Certified by the State of California, or ?Certified by U.S. Department of Veterans Affairs as a DVBE; or ?Certified as a DVBE with other certifying agencies under DCBA’s inclusion policy that meets the criteria set forth by: the State of California as a DVBE or is verified as a service-disabled veteran-owned small business by the Veterans Administration: and?Certified as a DVBE by the DCBA.*Business understands that only one of the above preferences will apply. in no instance shall ANY OF the above listed preference programs price or scoring preference be combined with any other County program to exceed fifteen percent (15%) in response to any County solicitation.DECLARATION: I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.? DCBA certification is attached.Name of Firm:County Webven No.:Print Name:Title:Signature:Date: Reviewer’s SignatureApprovedDisapprovedDateREQUIRED FORMS - EXHIBIT 8BIDDER’S EEO CERTIFICATION____________________________________________________________________________________Company Name____________________________________________________________________________________Address____________________________________________________________________________________Internal Revenue Service Employer Identification NumberGENERALIn accordance with provisions of the County Code of the County of Los Angeles, the Bidder certifies and agrees that all persons employed by such firm, its affiliates, subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America and the State of California.CERTIFICATIONYESNOBidder has written policy statement prohibitingdiscrimination in all phases of employment. ( )( )Bidder periodically conducts a self-analysis orutilization analysis of its work force.( )( )Bidder has a system for determining if its employmentpractices are discriminatory against protected groups. ( )( )When problem areas are identified in employment practices,Bidder has a system for taking reasonable corrective action to include establishment of goal and/or timetables.( )( )_________________________________________________________________________SignatureDate_____________________________________________________________________________Name and Title of Signer (please print)REQUIRED FORMS - EXHIBIT 9ATTESTATION OF WILLINGNESS TO CONSIDERGAIN/GROW PARTICIPANTSAs a threshold requirement for consideration for contract award, Bidder shall demonstrate a proven record for hiring GAIN/GROW participants or shall attest to a willingness to consider GAIN/GROW participants for any future employment opening if they meet the minimum qualifications for that opening. Additionally, Bidder shall attest to a willingness to provide employed GAIN/GROW participants access to the Bidder’s employee mentoring program, if available, to assist these individuals in obtaining permanent employment and/or promotional opportunities.To report all job openings with job requirements to obtain qualified GAIN/GROW participants as potential employment candidates, Contractor shall email: GAINGROW@DPSS. and BSERVICES@WDACS.. Bidders unable to meet this requirement shall not be considered for contract award.Bidder shall complete all of the following information, sign where indicated below, and return this form with their bid.Bidder has a proven record of hiring GAIN/GROW participants.______ YES (subject to verification by County) ______ NO Bidder is willing to provide DPSS with all job openings and job requirements to consider GAIN/GROW participants for any future employment openings if the GAIN/GROW participant meets the minimum qualifications for the opening. “Consider” means that Bidder is willing to interview qualified GAIN/GROW participants.______ YES______ NOBidder is willing to provide employed GAIN/GROW participants access to its employee-mentoring program, if available.______ YES______ NO______ N/A (Program not available)Bidder’s Organization: ________________________________________________________Signature: ____________________________________________________________________Print Name: ___________________________________________________________________Title: ________________________________________ Date: __________________________Telephone No: _____________________________ Fax No: ____________________________REQUIRED FORMS - EXHIBIT 10COUNTY OF LOS ANGELES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAMCERTIFICATION FORM AND APPLICATION FOR EXCEPTION The County’s solicitation for this Invitation for Bids is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program), Los Angeles County Code, Chapter 2.203. All bidders, whether a contractor or subcontractor, must complete this form to either certify compliance or request an exception from the Program requirements. Upon review of the submitted form, the County department will determine, in its sole discretion, whether the bidder is given an exemption from the pany Name:Company Address:City: State: Zip Code:Telephone Number:Solicitation For ____________ Services:If you believe the Jury Service Program does not apply to your business, check the appropriate box in Part I (attach documentation to support your claim); or, complete Part II to certify compliance with the Program. Whether you complete Part I or Part II, please sign and date this form below.Part I: Jury Service Program is Not Applicable to My BusinessMy business does not meet the definition of “contractor,” as defined in the Program, as it has not received an aggregate sum of $50,000 or more in any 12-month period under one or more County contracts or subcontracts (this exception is not available if the contract itself will exceed $50,000). I understand that the exception will be lost and I must comply with the Program if my revenues from the County exceed an aggregate sum of $50,000 in any 12-month period.My business is a small business as defined in the Program. It 1) has ten or fewer employees; and, 2) has annual gross revenues in the preceding twelve months which, if added to the annual amount of this contract, are $500,000 or less; and, 3) is not an affiliate or subsidiary of a business dominant in its field of operation, as defined below. I understand that the exception will be lost and I must comply with the Program if the number of employees in my business and my gross annual revenues exceed the above limits. “Dominant in its field of operation” means having more than ten employees and annual gross revenues in the preceding twelve months, which, if added to the annual amount of the contract awarded, exceed $500,000.“Affiliate or subsidiary of a business dominant in its field of operation” means a business which is at least 20 percent owned by a business dominant in its field of operation, or by partners, officers, directors, majority stockholders, or their equivalent, of a business dominant in that field of operation.My business is subject to a Collective Bargaining Agreement (attach agreement) that expressly provides that it supersedes all provisions of the Program.ORPart II: Certification of ComplianceMy business has and adheres to a written policy that provides, on an annual basis, no less than five days of regular pay for actual jury service for full-time employees of the business who are also California residents, or my company will have and adhere to such a policy prior to award of the contract.I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.Print Name:Title:Signature:Date:REQUIRED FORMS - EXHIBIT 11CHARITABLE CONTRIBUTIONS CERTIFICATION________________________________________________________________________Company Name________________________________________________________________________Address________________________________________________________________________Internal Revenue Service Employer Identification Number________________________________________________________________________California Registry of Charitable Trusts “CT” number (if applicable)The Nonprofit Integrity Act (SB 1262, Chapter 919) added requirements to California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act which regulates those receiving and raising charitable contributions.Check the Certification below that is applicable to your company. Bidder or Contractor has examined its activities and determined that it does not now receive or raise charitable contributions regulated under California’s Supervision of Trustees and Fundraisers for Charitable Purposes Act. If Bidder engages in activities subjecting it to those laws during the term of a County contract, it will timely comply with them and provide County a copy of its initial registration with the California State Attorney General’s Registry of Charitable Trusts when filed. ORBidder or Contractor is registered with the California Registry of Charitable Trusts under the CT number listed above and is in compliance with its registration and reporting requirements under California law. Attached is a copy of its most recent filing with the Registry of Charitable Trusts as required by Title 11 California Code of Regulations, sections 300-301 and Government Code sections 12585-12586. _____________________________________________________________________SignatureDate________________________________________________________________________Please Print Name and Title of SignerREQUIRED FORMS - EXHIBIT 12PRICING SHEET (INTENTIONALLY NOT ATTACHED)REQUIRED FORMS - EXHIBIT 13CERTIFICATION OF INDEPENDENT PRICE DETERMINATIONAND ACKNOWLEDGEMENT OF IFB RESTRICTIONSBy submission of this bid, Bidder certifies that the prices quoted herein have been arrived at independently without consultation, communication, or agreement with any other Bidder or competitor for the purpose of restricting competition.List all names and telephone number of person legally authorized to commit the Bidder.NAMEPHONE NUMBER____________________________________________________________________________________________________________________________________________________________________________________________________________NOTE:Persons signing on behalf of the Contractor will be required to warrant that they are authorized to bind the Contractor.List names of all joint ventures, partners, subcontractors, or others having any right or interest in this contract or the proceeds thereof. If not applicable, state “NONE”.Bidder acknowledges that it has not participated as a consultant in the development, preparation, or selection process associated with this IFB. Bidder understands that if it is determined by the County that the Bidder did participate as a consultant in this IFB process, the County shall reject this bid. Name of FirmPrint Name of Signer TitleSignature DateREQUIRED FORMS EXHIBIT 14CERTIFICATION OF COMPLIANCE WITH THE COUNTY’SDEFAULTED PROPERTY TAX REDUCTION PROGRAM Company Name:Company Address:City: State: Zip Code:Telephone Number: Email address:Solicitation/Contract For ____________ Services:The Proposer/Bidder/Contractor certifies that:□It is familiar with the terms of the County of Los Angeles Defaulted Property Tax Reduction Program, Los Angeles County Code Chapter 2.206; ANDTo the best of its knowledge, after a reasonable inquiry, the Proposer/Bidder/Contractor is not in default, as that term is defined in Los Angeles County Code Section 2.206.020.E, on any Los Angeles County property tax obligation; ANDThe Proposer/Bidder/Contractor agrees to comply with the County’s Defaulted Property Tax Reduction Program during the term of any awarded contract.- OR -□I am exempt from the County of Los Angeles Defaulted Property Tax Reduction Program, pursuant to Los Angeles County Code Section 2.206.060, for the following reason:__________________________________________________________________________________________________________________________________________________________________________________________________________________I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct.Print Name:Title:Signature:Date:REQUIRED FORMS - EXHIBIT 15ZERO TOLERANCE POLICY ON HUMAN TRAFFICKING CERTIFICATIONCompany Name:Company Address:City: State: Zip Code:Telephone Number: Email address:Solicitation/Contract for Prevention ServicesBIDDER CERTIFICATIONLos Angeles County has taken significant steps to protect victims of human trafficking by establishing a zero tolerance policy on human trafficking that prohibits contractors found to have engaged in human trafficking from receiving contract awards or performing services under a County contract.Bidder acknowledges and certifies compliance with Section 8.54 (Compliance with County’s Zero Tolerance Policy on Human Trafficking) of the proposed Contract and agrees that bidder or a member of his staff performing work under the proposed Contract will be in compliance. Bidder further acknowledges that noncompliance with the County's Zero Tolerance Policy on Human Trafficking may result in rejection of any bid, or cancellation of any resultant Contract, at the sole judgment of the County.I declare under penalty of perjury under the laws of the State of California that the information herein is true and correct and that I am authorized to represent this company.Print Name: FORMTEXT ?????Title: FORMTEXT ?????Signature: Date: FORMTEXT ?????REQUIRED FORMS - EXHIBIT 16INTENTIONALLY OMITTEDREQUIRED FORMS - EXHIBIT 17COMPLIANCE WITH FAIR CHANCE EMPLOYMENT HIRING PRACTICESCERTIFICATIONCompany Name:Company Address:City: State: Zip Code:Telephone Number: Email address:Solicitation/Contract for Prevention ServicesBIDDER/CONTRACTOR CERTIFICATIONThe Los Angeles County Board of Supervisors approved a Fair Chance Employment Policy in an effort to remove job barriers for individuals with criminal records. The policy requires businesses that contract with the County to comply with fair chance employment hiring practices set forth in California Government Code Section 12952, Employment Discrimination: Conviction History (California Government Code Section 12952), effective January 1, 2018.Bidder/Contractor acknowledges and certifies compliance with fair chance employment hiring practices set forth in California Government Code Section 12952 and agrees that proposer/contractor and staff performing work under the Contract will be in compliance. Proposer/Contractor further acknowledges that noncompliance with fair chance employment practices set forth in California Government Code Section 12952 may result in rejection of any proposal, or termination of any resultant Contract, at the sole judgment of the County.I declare under penalty of perjury under the laws of the State of California that the information herein is true and correct and that I am authorized to represent this company.Print Name: FORMTEXT ?????Title: FORMTEXT ?????Signature: Date: FORMTEXT ????? ................
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